Retrieval of critically ill adults using extracorporeal membrane oxygenation: the nine-year experience in New South Wales.

In New South Wales, a coordinated extracorporeal membrane oxygenation (ECMO) retrieval program has been in operation since 2007. This study describes the characteristics and outcomes of patients transported by this service. We performed a retrospective observational study and included patients who were transported on ECMO to either of two adult tertiary referral hospitals in Sydney, New South Wales, between February 28, 2007 and February 29, 2016. One hundred and sixty-four ECMO-facilitated transports occurred, involving 160 patients. Of these, 118 patients (74%) were treated with veno-venous (VV) ECMO and 42 patients (26%) were treated with veno-arterial ECMO. The mean (standard deviation, SD) age was 40.4 (15.0) years. Seventy-seven transports (47%) occurred within metropolitan Sydney, 52 (32%) were from rural or regional areas within NSW, 17 (10%) were interstate transfers and 18 (11%) were international transfers. Transfers were by road (58%), fixed wing aircraft (27%) or helicopter (15%). No deaths occurred during transport. The median (interquartile range) duration of ECMO treatment was 8.9 (5.2-15.3) days. One hundred and nineteen patients (74%) were successfully weaned from ECMO and 109 (68%) survived to hospital discharge or transfer. In patients treated with VV ECMO, age, sequential organ failure assessment score, pre-existing immunosuppressive disease, pre-existing diabetes, renal failure requiring dialysis and failed prone positioning prior to ECMO were independently associated with increased mortality. ECMO-facilitated patient transport is feasible, safe, and results in acceptable short-term outcomes. The NSW ECMO Retrieval Service provides specialised support to patients with severe respiratory and cardiovascular illness, who may otherwise be too unstable to undergo inter-hospital transfer to access advanced cardiovascular and critical care services.

The impact of a specialized inpatient and day patient group programme on clinical outcome in older adolescents and young adults with mental illness.

Introduction Effective transition from child and adolescent mental health services (CAMHS) to adult services is one of the main challenges currently facing child psychiatry today The Young Adult 1Programme (YAP) based at St. Patrick's University Hospital Dublin, is a group based day programme especially designed to meet the needs of younger people aged 18-25 and support them through this difficult period. Aims To examine the effectiveness of participation in YAP for young adults with mental illness. To determine whether participation in particular aspects of the programme prove more beneficial and what factors might be associated with outcome. METHOD: All patients enrolled in YAP between 1 September 2011 and 31 August 2012 were included in the study. Each patient was assessed using the Health of the Nation Outcome Scales (HONOS) and Global Assessment of Functioning (GAF) rating scale before beginning the programme and after discharge in order to evaluate improvement. The frequency of attendance at individual group sessions was recorded. Patient and illness variables were also recorded, for example demographics, diagnosis. RESULTS: A total of 101 service users were in enrolled in YAP during this 12-month period. Eight service users could not be used for analysis, as they did not have a complete data set, mostly due to failure to attend for discharge HONOS/GAF ratings Using a paired sample t-test, there is a significant reduction in HONOS: Mean df=1.3, s.d.=1.09 (95% CI=1.08-1.53), p<0.001 Using a paired sample t-test, there is a significant increase in GAF: Mean df=9.25, s.d.=7.69 (95% CI=7.66-10.83), p<0.001 Improvements in HONOS and GAF scores are significantly correlated with better attendance at the programme (p<0.04, <0.00 respectively). CONCLUSION: More attendance at YAP sessions correlates with better improvement in both HONOS and GAF rating scores.

Predictors of Acute Kidney Injury in Cardiac Transplantation.

BACKGROUND: Acute kidney injury (AKI) is an outcome that represents a significant increase in morbidity and mortality rates; however, limited information exists about the incidence of AKI after cardiac transplantation. METHODS: This single-center, retrospective study from 2009 to 2014 analyzed pre-, intra-, and post-operative characteristics of 111 patients who underwent orthotopic cardiac transplantation to identify risk factors for AKI and validate findings of existing literature. RESULTS: AKI based on the RIFLE criteria (risk, injury, failure, loss, and end-stage) occurred in 65 patients (58.6%) during the hospitalization period, with 38 patients requiring early dialysis. Risk factors for AKI were longer cardiopulmonary bypass duration (P = .008), higher packed cell (P = .004) and cryoprecipitate (P = .022) transfusions, and post-operative bleeding with subsequent surgical re-exploration (P = .008). The development of AKI was also associated with longer inotropic (P ≤ .001) and ventilation duration (P ≤ .001) as well as higher mortality rates (P = .048). CONCLUSIONS: AKI after cardiac transplantation is prevalent and prognostically significant. Although there is yet to be a strategy that conclusively demonstrated its ability to prevent AKI after cardiac surgery, therapies targeted at modifiable risk factors may offer protection against this outcome.

The Pressure Flow Relationship of the Internal Mammary Artery after Offpump Anastomosis to the Left Anterior Descending Coronary Artery

Objective: To assess the pressure flow relationship of the internal mammary artery (IMA) in situ; after skeletonisation and after anastomosis to the left anterior descending (LAD) coronary artery; using either halothane; sevoflurane or propofol as an anaesthetic agent. Methods: 15 Pigs were used in total; five received halothane; five sevoflurane and five propofol as an anaesthetic agent. The flow in the internal mammary artery in each of the pigs; was measured at various arterial pressures. This was done with the IMA in situ; then after dissecting the artery off the chest wall using the skeletonisation technique and finally after offpump grafting to the left anterior descending coronary artery. Results: The pressure flow relationship of the internal mammary artery after skeletonisation was found to be linear (r=0.8650). The pressure flow correlation after grafting the skeletonised internal mammary artery to the left anterior descending coronary artery was found to be similarly linear (r=0.8766). In the sevoflurane subgroup; with the IMA still in situ; a degree of autoregulation was found to be present; but after skeletonisation this was subsequently lost (p=0.011). Conclusions: The pressure flow relationship in the internal mammary artery after skeletonising the vessel and after OPCAB anastomosis to the LAD was found to be linear. In the subgroup of pigs receiving sevoflurane; some degree of autoregulation was demonstrated in the in situ IMA. This remnant of autoregulation was lost after skeletonisation and after grafting of the vessel to the left anterior descending coronary artery

Prevention of perinatal group B streptococcal disease: screening practice in public hospitals in Victoria.

OBJECTIVES: To survey clinical protocols for prevention of early-onset group B streptococcal disease (EOGBSD) of the newborn in public maternity hospitals. DESIGN: Postal questionnaire with telephone follow-up when required. SETTING: All hospitals that undertook deliveries in public patients in the State of Victoria, November 1997 to January 1998. RESULTS: The survey was sent to 84 hospitals: 71 responded and 64 met the criteria and provided usable data (76% response rate). These 64 represented 42,784 births (68% of births in Victoria in 1996). Most hospitals (62; 97%) undertook actions that would identify and treat pregnant women at risk of EOGBSD. 48 (75%) performed bacteriological screening for maternal GBS carriage, but only 20 of these had a unified protocol. Screening was mostly by low vaginal swab (15 hospitals) and before 30 weeks' gestation (12 hospitals). Low vaginal swab plus anal swab was used in only one hospital. Bacteriological screening was significantly more common in metropolitan hospitals than in rural hospitals (100% versus 67%; P = 0.007, Fisher's exact test). Targeting of prophylaxis by recognised risk factors was reported by 59 (92%) hospitals, 45 of which also undertook screening. There was considerable variation in the specific risk factors used. CONCLUSIONS: While there was clearly widespread awareness of EOGBSD in Victorian public hospitals, prevention programs varied considerably. The development of consensus practice guidelines might improve EOGBSD prevention, reducing morbidity, mortality and costs.

Serum levels of quinine following intramuscular administration to children.

The serum quinine level was assayed in 31 children four hours after receiving an intramuscular injection of quinine dihydrochloride; in 14 children the level was also assayed 2 hours after the injection. The quinine was quickly absorbed from muscle, with serum quinine levels being significantly higher at 2 hours than at 4 hours. The injections were not particularly painful, and muscle necrosis was not observed. Quinine is rapidly absorbed following intramuscular injection, and is a safe and reliable method of administering the drug to children with severe malaria. In most situations in Papua New Guinea (PNG), intramuscular administration of quinine is preferable to intravenous infusion.